NCC240541_FRO Submitted_20240229

I <50 coLNAT, FINANCIAL RESPONSIBILITY/OWNERSHIP FORM �r;(�E SIN ciu'�'y
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act before
this form and an acceptable erosion and sedimentation control plan have been completed and
approved by Henderson County Site Development Department. (Please type or print and, if the
question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Sign the original form in BLUE INK.
Part A.1. Project Name Lakewood Road Apartments
2. Location of land-disturbing activity: County Henderson City Hendersonville
Highway/Street Lakewood Road Latitude35•3470 Longitude-82.4474
Property Identification Number(s) PIN's 9579-39-2060,9579-3r8-2595, 9,579-29-0718, 9579-19-2770
3. Approximate date land-disturbing activity will commence:September 2023
4. Purpose of development(residential, commercial, industrial, institutional, etc.):Residential
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas):1 7.50
6. Amount of fee enclosed: $5600 . The application fee of$300.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount include a$200.00 plan review fee to
land disturbance fees. (Example: 8.10 ac= $2,900.00).
7. Has an erosion and sediment control plan been filed? Yes No EnclosedX
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity.
NameTravis Fowler E-mail [e-mail]
Telephone [phone] _
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Lakewood Hendersonville LLC 828-577-4201
Name Telephone
542 South Caldwell Street 542 South Caldwell St
Current Mailing Address Current Street Address
Brevard NC 28712 Brevard NC 28712
City State Zip City State Zip
10. Deed Book No.857 Page No.631 Provide a copy of the most current deed.
Part B. 1051 453
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet.) If the company or firm is a sole proprietorship,
the name of the owner or manager maybe listed as the financially responsible party.
First Victory, Inc. [e-mail]
Name E-mail Address
542 South Caldwell Street 542 South Caldwell Street
Current Mailing Address Current Street Address
Brevard NC 2872 Brevard NC 28712
City State Zip City State Zip
Telephone[phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Travis Fowler [e-mail]
Name of Registered Agent E-mail Address
542 South Caldwell Street 542 South Caldwell Street
Current Mailing Address Current Street Address
Brevard NC 28712 Brevard NC 28712
City State Zip City State Zip
Telephone [phone]
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Travis F Ier Chief Executive Officer
Type or int a Title or Authority
"C.1% ZpZ3
Signature Date
I, Sabrina i'O ?QCP , a Notary Public of the County of TrQns vdn i'
State of Nor+r1 Coroliicl , hereby certify that Tca ciS Fr t ote.0
appeared personally before me this day and being duly sworn acknowledged that the above
form was executed by him.
Witness my hand and notarial seal, this ao day of Sepi-ember , 20 23
qC (l.bti. , Paco
yr ,►� rnNotary Public F
v. Transylvania S. Notary
ty
12 My Comm.Exp. s My commission expires (a- goal
, 02-21.2027 Ir
04
411111111111